[Sonography with color and pulsed Doppler in fetal pulmonary malformations]. / Apport de l'échographie avec Doppler couleur et pulsé dans les malformations pulmonaires du foetus.

OBJECTIVE: Evaluate the advantages of color Doppler and pulsed Doppler in the diagnosis and prognosis of fetal pulmonary malformations. MATERIALS AND METHOD: This retrospective study of 24 fetuses explored pulmonary malformations using sonography. A classification into four groups was made based on the presence of cysts and the echogenicity of the lesion, then analysis of video recordings including Doppler with an interpretation chart: afferent vessel, color chart, spectrum shape (afferent vessel and within the malformation) to determine the contribution of Doppler within each group. RESULTS: Four lesions were avascular: bronchogenic cysts (three cases), subphrenic sequestration (one case). The other lesions were vascularized and color Doppler determined the source of vascularization feeding the malformation: branches of the pulmonary artery in 13 cases (eight cases of cystic adenomatoid disease, two cases of atresia, and three airway obstacles) or the aorta in seven cases (pulmonary sequestrations) with pulmonary venous return, six cases (intralobular sequestrations), or systemic venous return, one case (extralobular sequestration). The pulsed Doppler recording in the malformation (six cases) completed the color Doppler examination by showing the different spectrum shapes according to the aortic or pulmonary source of flow. The color chart matched in three cases (normal pulmonary segmentation) and was heterogeneous in eight cases (parenchymatous dysplasia). Furthermore, perfusion intensity was correlated with lesion progression. CONCLUSION: Color Doppler and pulsed Doppler provided a more precise diagnosis of these malformations and seems to contribute prognostic information.

[Management of abdominal trauma in children]. / La prise en charge des traumatismes abdominaux de l'enfant.

Management of abdominal trauma in children has considerably changed over the last fifteen years. This is mainly due to advances in imaging techniques combined with a more conservative approach. Non-surgical management is frequently preferred with close clinical and biological surveillance, in addition to comprehensive imaging evaluation. The imaging work up must be adapted to this conservative approach. The increasing availability of helical CT technology and Doppler US imaging can be used to advantage in the evaluation of these patients. Euratom Directive 97-43 identifies children as a particular subgroup of patients with regards to exposure to ionizing radiation thus requiring us to reconsider the routine use of CT in this patient subpopulation and promoting the use of alternate imaging techniques. Based on a review of the literature as well as our own experience, where we currently favor US with selective use of CT, the advantages and pitfalls of each imaging technique will be reviewed. Ultimately, the imaging protocol for each patient should be based on availability, expertise, and individual clinical setting.

Association of N-acetylcysteine and glucagon during percutaneous cholangiography in the treatment of inspissated bile syndrome.

Inspissated bile syndrome (IBS) is a rare neonatal disease. In the majority of cases, it resolves spontaneously and treatment is conservative. Follow-up is recommended with close monitoring of laboratory tests. When IBS does not resolve spontaneously, a catheter can be inserted into the gallbladder for cholangiography, which allows irrigation and drainage. Despite this treatment, some biliary tract obstruction may persist. We report on the case of a 3-month-old infant whose continuous biliary obstruction caused by IBS was successfully managed by interventional radiology with the association of N-acetylcysteine and glucagon. Even as first-line agents, these would allow more rapid clearance of gallstones and prevent infectious complications of indwelling catheters as well as decrease the need for surgery.

Idiopathic varicocele in children and adolescents--which therapeutic choice?

61 children were studied and treated between January 1986 and September 1993 for idiopathic varicocele. The aim of our study was to evaluate the advantages and disadvantages of the different techniques and to show the progression to a greater efficacy. The mean age at the time of therapy was 14 years, ranging from 7 to 16 years. All children presenting with pain or testicular asymmetry were treated. Four asymptomatic children were followed for 2 years before treatment. 36 children were treated by surgical ligature via the inguinal approach; 8 with a resection of the varicose veins as far as the tunica vaginalis. 14 children were treated by percutaneous sclerotherapy including 1 patient following unsuccessful classical surgical treatment. 12 children were treated by surgical inguinal ligature associated with peroperative phlebography and thrombosis. 56 children were reviewed postoperatively over a period which varied from 2 months to 4 years (5 lost to follow-up). For the 36 classical ligatures: 25 good results, but 9 hydroceles (5 out 8 varicose resections): 70% good results. 7 failures and 4 lost to follow-up. For the 14 percutaneous sclerotherapy: 4 technical failures (impossibility to catheterize the spermatic vein): 10 good results. For the 12 ligatures with peroperative phlebography and thrombosis: 11 good results and 1 lost to follow-up. All the above procedures were carried out at our out-patient clinic. The therapeutic choice will therefore have to take into consideration a procedure which produces the lowest morbidity rate and proves to be the most effective. The association of surgical ligature, phlebography and thrombosis meets these requirements.

[Perirenal necrotic and cystic pseudotumors in children. Report of two cases]. / Pseudotumeurs nécrotiques et enkystées périrénales de l'enfant. A propos de deux observations.

This work describes two cases of necrotic, encysted pseudotumors of unknown origin, in children; the lesions located on the anterior side of the kidney, near its inferior pole were remarkable for their size and their numerous adhesions to adjacent structures. The hypothesis of an initial infectious or tumoral mechanism are discussed, particularly the similarities supported by both lesions with the regressive patterns of some neuroblastomas.

[Postnatal echography and cystography after prenatal diagnosis of minor dilatation of the kidney pelvis. Prospective study of 89 cases]. / Echographie et cystographie postnatales après diagnostic prénatal d'une dilatation mineure du bassinet. Etude prospective sur 89 cas.

We evaluated postnatal management after the prenatal diagnosis of moderate dilatation of the renal pelvis (antero-posterior diameter superior to 1 mm per month of pregnancy and inferior to 15 mm at full term). Eighty-nine neonates who had a moderate dilatation in utero were evaluated by ultrasound and voiding cysto-urethrography. Ultrasound was performed between day 2 and day 7 in 83 cases, after day 7 in 6 cases. Voiding cysto-urethrography was performed during first month in 80 cases, after this period in 9 cases. Sixty-five neonates were shown to have a malformation of the urinary tract: reflux (n = 27), megaureter (n = 20), uretero-pelvic junction obstruction (n = 19), renal duplication (n = 7), posterior urethral valves (n = 2), horseshoe kidney (n = 1), ureteric cyst (n = 1). Reflux which is frequent in neonates with urinary tract infection, is the most frequent cause of moderate dilatation of the fetal renal pelvis. Combination of ultrasound and voiding cysto-urethrography in neonates allows a quick, full diagnosis. It helps rationalize the use of prophylactic antibiotic treatment.

[Sedation with oral hydroxyzine and rectal chloral hydrate in pediatric MRI and CT]. / Sédation par hydroxyzine orale et hydrate de chloral rectal en IRM et TDM pédiatriques.

AIM: To assess the efficacy and risks of oral hydroxyzine and rectal chloral hydrate to sedate children undergoing CT or MRI. PATIENTS AND METHODS: 110 children underwent 117 studies. Medical history, treatments, doses per kg of sedative drugs, study quality, sedation time and side effects were prospectively recorded. RESULTS: 25 minutes was the mean time necessary to put children to sleep, 59 minutes was the mean time of sedation 96% of studies were interpretable. 2 children showed transient side effects. CONCLUSION: This sedation regimen appeared efficient. However, its limitations and risks have to be known by radiologists. Sedation-related problems also have to be considered by hospital managers when a new CT or MR equipment is being acquired.

[Retrograde cystography after a first episode of acute pyelonephritis in the child and adolescent]. / Cystographie rétrograde après un premier épisode de pyélonéphrite aiguë chez la fillette et l'adolescente.

In spite of its invasiveness, voiding cystourethrography remains the gold-standard examination for detecting vesico-ureteric reflux. The aim of this study was to determine if voiding cysto-urethrography is useful at any pediatric age in girls after a first acute pyelonephritis. 152 patients have been retrospectively studied. Both reflux frequency and grade progressively decreased according to age. Sonography was unable to predict reflux. In more than 3-year-old girls, 8/30 children with reflux had voiding dysfunction. We suggest clinical and/or a flow-metric evaluation for voiding dysfunction prior to voiding cystourethrography. After 9 years, reflux was so rare that voiding cystourethrography should be discussed on an individual basis.

[Evolution and radiologic surveillance on community-acquired pneumonia in children]. / Evolution et surveillance radiologiques des pneumopathies communautaires de l'enfant.

Although useful for the diagnosis of lower respiratory tract infections, chest X-rays have a weak specificity in the etiological diagnosis. It is of particular interest when complications are suspected. A radiological follow-up allows to exclude sequellae or a preexisting pulmonary abnormality; however follow-up X-rays are to be delayed 2 to 3 weeks after the clinical recovery due to the late radiological recovery. CT is indicated as a complementary investigation in cases of complications and sequellae.

[Selective indications of skull radiography after head injury in children]. / Indications sélectives de la radiographie du crâne après traumatisme de la voûte chez l'enfant.

PURPOSE OF THE STUDY: Skull X-rays are systematically performed on children after head injuries in most hospitals. However, the discovery of a skull fracture as an isolated finding rarely warrants intervention. In february 1994, we stopped performing systematical skull X-rays in children after head injuries. We report the results of this experience. MATERIALS AND METHODS: Since February 1994, only children with possible skull penetration, depressed fracture, or presenting signs of basilar fracture had X-ray examination. Facial injuries were excluded in this study. In case of focal neurologic signs, neurosurgical consultation, or emergency CT examination, or both were performed. In case of change of consciousness at the time of injury or subsequently, the child was hospitalised for clinical observation for 48 hours, but no X-ray examination was performed. Children without any neurological signs or change of consciousness were discharged to their homes after they were given a head-injury instruction sheet, and if a second person could observe them for signs indicating that they belong to a higher risk group, but no X-ray examination was performed. RESULTS: An average of 241 children per month were presented at the Children Emergency Unit after head trauma. An average of twenty-one X-ray examinations per month were performed instead of 194/month before february 1994. This represented a decrease of 2000 X-ray examinations per year. There was no undiagnosed neurological complication, and the number of children staying in the hospital for clinical supervision did not increase. DISCUSSION: Skull radiographies only show fractures and do not afford visibility of either brain or blood to demonstrate an intracranial injury. The presence of a skull fracture without neurological abnormalities is of little significance. Harwood-Nash reported that 60 per cent of the children with extradural hematoma, 85 per cent of the children with subdural hematoma and 35 per cent of the children with brain damage did not have any associated skull fracture. Clinical examination is essential, and it would be a mistake to be reassured about the severity of a head trauma because skull X-rays are normal. CONCLUSION: Routine skull X-rays after head trauma are not justified either for financial or radioprotection reasons. In this study, more than half of the children were less than five years old and ran a higher risk of irradiation.

[Fatigue fractures]. / Les fractures de fatigue.

Stress fractures are extremely common microtraumatic lesions which occur in specific areas of healthy bones. Since clinical findings are often misleading and radiological signs are known to be delayed, diagnosis can be uneasy. In some instances, infectious or tumoral diseases have to be ruled out. Such difficult cases are shown to stress on the potential interest of CT scanner and magnetic resonance imaging.